Cycle 1
Health 2025-06-12 · Fire 2025-06-12
18 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (5 deficiencies)
2 fire-safety deficiencies
Top issue: Emergency Preparedness (2 deficiencies)
Chicago, IL
Lakeview Rehab & Nursing Center
1-star overall rating with 2-star inspections with abuse icon flag with $82,329 in total fines with 18 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
735 West Diversey, Chicago, IL
(773) 348-4055
Overall
1 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
178
Certified beds
Average residents
141
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Infinity Healthcare Consulting
Operator or chain grouping
Approved since
1989-11-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
70 facilities
Chain averages 2 overall / 2 health / 2 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.61
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.61
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
1.99
Nurse aide staffing · state 2.13 · national 2.35
Total nurse hours
3.20
All reported nurse hours · state 3.49 · national 3.89
Licensed hours
1.21
RN + LPN hours · state 1.36 · national 1.54
Weekend hours
2.84
Weekend nurse staffing · state 3.09 · national 3.43
Weekend RN hours
0.53
Weekend registered nurse coverage · state 0.56 · national 0.47
Physical therapist
0.01
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
0.50
CMS adjusted RN staffing hours
Adjusted total hours
2.67
CMS adjusted total nurse staffing hours
Case-mix index
1.64
Higher values indicate more complex resident acuity
RN turnover
38%
Annual RN turnover · state 44% · national 45%
Total nurse turnover
34%
Annual nurse turnover · state 46% · national 46%
SNF VBP
Value-based purchasing
Program rank
11,832
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
15.08
Composite VBP score used to determine payment impact.
Payment multiplier
0.9814
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 20.20% · Performance 21.72% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
2.08
Baseline 7.12% · Performance 7.21% · Measure score 2.08 · Achievement 2.08 · Improvement 0
Total nurse turnover
3.44
Baseline 60.42% · Performance 49.61% · Measure score 3.44 · Achievement 3.44 · Improvement 2.54
Adjusted total nurse staffing
0.50
Baseline 2.11 hours · Performance 2.48 hours · Measure score 0.50 · Achievement 0 · Improvement 0.50
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.51% |
10.72%
0.2 pts better
|
No Different than the National Rate · Eligible stays 57 · Observed rate 10.53% · Lower 95% interval 6.79% |
| Discharge to community | 39.33% |
50.57%
11.2 pts worse
|
No Different than the National Rate · Eligible stays 34 · Observed rate 23.53% · Lower 95% interval 25.22% |
| Medicare spending per beneficiary | 1.22 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 53 · Denominator 53 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 53 |
| Discharge self-care score | 10.71% |
53.69%
43 pts worse
|
Numerator 3 · Denominator 28 |
| Discharge mobility score | 3.57% |
50.94%
47.4 pts worse
|
Numerator 1 · Denominator 28 |
| Pressure ulcers or injuries, new or worsened | 5.66% |
2.29%
3.4 pts worse
|
Numerator 3 · Denominator 53 · Adjusted rate 4.42% |
| Healthcare-associated infections requiring hospitalization | 7.21% |
7.12%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 36 · Observed rate 8.33% · Lower 95% interval 3.92% |
| Staff COVID-19 vaccination coverage | 1.86% |
8.2%
6.3 pts worse
|
Numerator 3 · Denominator 161 |
| Staff flu vaccination coverage | 1.86% |
42%
40.1 pts worse
|
Numerator 3 · Denominator 161 |
| Discharge function score | 0% |
56.45%
56.5 pts worse
|
Numerator 0 · Denominator 28 |
| Transfer of health information to provider | 96% |
95.95%
About the same
|
Numerator 24 · Denominator 25 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 0% |
25.2%
25.2 pts worse
|
Numerator 0 · Denominator 31 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.7 |
2.0
0.3 pts better
|
1.9
0.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 2.1 · Expected 2.4 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.4 |
2.3
0.9 pts better
|
1.8
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.6 · Expected 1.9 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 36.9% |
89.6%
52.7 pts worse
|
93.4%
56.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.2% · Q2 25.0% · Q3 50.0% · Q4 43.6% · 4Q avg 36.9% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 86.8% |
91.6%
4.8 pts worse
|
95.5%
8.7 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 86.8% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.4% |
3.3%
2.9 pts better
|
3.3%
2.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 74.8% |
50.3%
24.5 pts worse
|
11.4%
63.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 75.5% · Q2 79.2% · Q3 71.0% · Q4 74.0% · 4Q avg 74.8% |
| Percentage of long-stay residents who lose too much weight | 4.8% |
6.5%
1.7 pts better
|
5.4%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.1% · Q2 5.5% · Q3 3.0% · Q4 3.0% · 4Q avg 4.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 6.6% |
18.5%
11.9 pts better
|
19.6%
13 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.0% · Q2 7.7% · Q3 5.9% · Q4 5.9% · 4Q avg 6.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 27.9% |
22.8%
5.1 pts worse
|
16.7%
11.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.7% · Q2 27.4% · Q3 31.7% · Q4 23.7% · 4Q avg 27.9% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 6.2% |
17.2%
11 pts better
|
16.3%
10.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.0% · Q2 6.0% · Q3 8.2% · Q4 6.6% · 4Q avg 6.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 3.8% |
15.0%
11.2 pts better
|
14.9%
11.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 4.7% · Q3 4.7% · Q4 3.2% · 4Q avg 3.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.7% |
1.1%
0.6 pts worse
|
1.0%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 1.3% · Q3 1.2% · Q4 1.8% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.2% |
1.7%
1.5 pts better
|
1.7%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.8% · Q3 0.0% · Q4 0.0% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 23.4% |
21.3%
2.1 pts worse
|
19.8%
3.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.5% · Q2 25.2% · Q3 23.1% · Q4 21.9% · 4Q avg 23.4% |
| Percentage of long-stay residents with pressure ulcers | 4.7% |
5.2%
0.5 pts better
|
5.1%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.2% · Q2 7.3% · Q3 3.2% · Q4 3.4% · 4Q avg 4.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 19.2% |
68.8%
49.6 pts worse
|
81.7%
62.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 27.4% · Q2 10.4% · Q3 19.3% · Q4 22.7% · 4Q avg 19.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.6% |
14.0%
2.4 pts better
|
12.0%
0.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.6% · Observed 14.6% · Expected 14.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.1% |
2.3%
1.2 pts better
|
1.6%
0.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 0.0% · Q3 0.0% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 8.8% |
63.0%
54.2 pts worse
|
79.7%
70.9 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 8.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 28.4% |
26.2%
2.2 pts worse
|
23.9%
4.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 28.4% · Observed 34.1% · Expected 28.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-05-23 · Fire 2024-05-23
23 health deficiencies
Top issue: Quality of Life and Care (10 deficiencies)
1 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Cycle 3
Health 2023-04-14 · Fire 2023-04-14
35 health deficiencies
Top issue: Quality of Life and Care (7 deficiencies)
2 fire-safety deficiencies
Top issue: Emergency Preparedness (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-06-12
E13 · Emergency Preparedness Deficiencies
Fire Safety
Develop Emergency Preparedness policies and procedures.
Corrected 2025-06-25
F · Potential for more than minimal harm
2025-06-12
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2025-06-25
F · Potential for more than minimal harm
2024-05-23
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2024-06-14
F · Potential for more than minimal harm
2023-04-14
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2023-05-08
F · Potential for more than minimal harm
2023-04-14
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2023-05-12
Inspection history
Recent health citations
G · Actual harm
2025-10-10
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-09-09
F · Potential for more than minimal harm
2025-06-12
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-06-25
F · Potential for more than minimal harm
2025-06-12
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2025-06-25
F · Potential for more than minimal harm
2025-06-12
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-06-25
F · Potential for more than minimal harm
2025-06-12
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2025-06-25
E · Potential for more than minimal harm
2025-06-12
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-06-25
E · Potential for more than minimal harm
2025-06-12
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-06-25
E · Potential for more than minimal harm
2025-06-12
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-06-25
E · Potential for more than minimal harm
2025-06-12
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2025-06-25
E · Potential for more than minimal harm
2025-06-12
F813 · Nutrition and Dietary Deficiencies
Health
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Corrected 2025-06-25
D · Potential for more than minimal harm
2025-06-12
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-06-25
D · Potential for more than minimal harm
2025-06-12
F605 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Corrected 2025-06-25
D · Potential for more than minimal harm
2025-06-12
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2025-06-25
D · Potential for more than minimal harm
2025-06-12
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-06-25
D · Potential for more than minimal harm
2025-05-29
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-06-20
D · Potential for more than minimal harm
2025-05-08
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-05-23
D · Potential for more than minimal harm
2025-03-25
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-04-04
D · Potential for more than minimal harm
2025-03-25
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-04-04
D · Potential for more than minimal harm
2024-12-20
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-01-05
D · Potential for more than minimal harm
2024-10-11
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-10-30
D · Potential for more than minimal harm
2024-08-22
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2024-08-30
G · Actual harm
2024-07-12
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-07-27
G · Actual harm
2024-07-12
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-07-27
G · Actual harm
2024-07-12
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-07-27
D · Potential for more than minimal harm
2024-07-12
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-07-27
F · Potential for more than minimal harm
2024-05-23
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-06-21
F · Potential for more than minimal harm
2024-05-23
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2024-06-21
F · Potential for more than minimal harm
2024-05-23
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2024-06-21
F · Potential for more than minimal harm
2024-05-23
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-06-21
F · Potential for more than minimal harm
2024-05-23
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-06-21
E · Potential for more than minimal harm
2024-05-23
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2024-06-21
E · Potential for more than minimal harm
2024-05-23
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2024-06-21
E · Potential for more than minimal harm
2024-05-23
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-06-21
D · Potential for more than minimal harm
2024-05-23
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-06-21
D · Potential for more than minimal harm
2024-05-23
F676 · Quality of Life and Care Deficiencies
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2024-06-21
D · Potential for more than minimal harm
2024-05-23
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2024-06-21
D · Potential for more than minimal harm
2024-05-23
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-06-21
D · Potential for more than minimal harm
2024-04-08
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-04-21
F · Potential for more than minimal harm
2024-03-29
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2024-04-11
D · Potential for more than minimal harm
2024-03-29
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-04-11
D · Potential for more than minimal harm
2024-03-29
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2024-04-11
G · Actual harm
2023-11-17
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-12-08
E · Potential for more than minimal harm
2023-11-17
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2023-12-08
E · Potential for more than minimal harm
2023-11-17
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-12-08
D · Potential for more than minimal harm
2023-11-17
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-12-08
D · Potential for more than minimal harm
2023-11-17
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-12-08
F · Potential for more than minimal harm
2023-08-25
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-09-15
G · Actual harm
2023-07-28
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-08-10
D · Potential for more than minimal harm
2023-07-28
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-08-10
D · Potential for more than minimal harm
2023-07-28
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2023-08-10
G · Actual harm
2023-05-19
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-05-30
F · Potential for more than minimal harm
2023-04-14
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-05-05
F · Potential for more than minimal harm
2023-04-14
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2023-05-05
F · Potential for more than minimal harm
2023-04-14
F887 · Infection Control Deficiencies
Health
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Corrected 2023-05-16
F · Potential for more than minimal harm
2023-04-14
F888 · Infection Control Deficiencies
Health
Ensure staff are vaccinated for COVID-19
Corrected 2023-05-05
E · Potential for more than minimal harm
2023-04-14
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-05-05
E · Potential for more than minimal harm
2023-04-14
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2023-05-05
E · Potential for more than minimal harm
2023-04-14
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2023-05-05
E · Potential for more than minimal harm
2023-04-14
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-05-18
E · Potential for more than minimal harm
2023-04-14
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-05-05
D · Potential for more than minimal harm
2023-04-14
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2023-05-05
D · Potential for more than minimal harm
2023-04-14
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-05-05
D · Potential for more than minimal harm
2023-04-14
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-05-05
D · Potential for more than minimal harm
2023-04-14
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-05-05
D · Potential for more than minimal harm
2023-04-14
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-05-05
D · Potential for more than minimal harm
2023-04-14
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-05-05
D · Potential for more than minimal harm
2023-04-14
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-05-05
D · Potential for more than minimal harm
2023-04-14
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-05-05
D · Potential for more than minimal harm
2023-04-14
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2023-05-05
C · Minimal harm
2023-04-14
F577 · Resident Rights Deficiencies
Health
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Corrected 2023-05-05
C · Minimal harm
2023-04-14
F865 · Administration Deficiencies
Health
Have a plan that describes the process for conducting QAPI and QAA activities.
Corrected 2023-05-05
C · Minimal harm
2023-04-14
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2023-05-05
E · Potential for more than minimal harm
2023-03-09
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-03-20
E · Potential for more than minimal harm
2023-03-09
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2023-03-20
E · Potential for more than minimal harm
2023-03-09
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2023-03-20
D · Potential for more than minimal harm
2023-03-09
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2023-03-20
Penalties and ownership
What sits behind the stars
$42,697
2023-11-17
Fine
Fine · fine $42,697
Fine
$21,078
2023-07-28
Fine
Fine · fine $21,078
Fine
$18,554
2023-04-14
Fine
Fine · fine $18,554
Fine
$0
2023-04-14
Payment Denial
Payment Denial · denial start 2023-05-28 · 2 days
2 day denial
Ownership
Blisko, Michael
5% Or Greater Direct Ownership Interest · Individual
Gubin Enterprises Limited Partnership
5% Or Greater Direct Ownership Interest · Organization
Borek, Daniel
5% Or Greater Direct Ownership Interest · Individual
Graber, Joshua
W-2 Managing Employee · Individual
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